Bring out the relationship between social class and mortality. (2011)
Mortality is the hardest measure of what Max Weber called life chances — the probabilities of advantage that follow from a person’s market position. Where death rates vary systematically by class, stratification is no longer a matter of prestige or attitude but embodied: inequality written into the body’s survival.
The classic evidence: a gradient, not a threshold
- The Black Report (1980), from the British working group chaired by Sir Douglas Black, found class differences in mortality persisting, and in places widening, after three decades of a national health service. It weighed four explanations: artefact (the gradient is a measurement effect), social selection (the unhealthy drift downwards), cultural-behavioural (class differences in smoking, diet, drink) and materialist-structural (income, housing, conditions of work), concluding for the materialist.
- Michael Marmot‘s Whitehall studies removed the obvious objections. Whitehall I (1967-77) followed over 17,500 male British civil servants — all employed, all covered by the same health service — and found the lowest grade dying at roughly three times the rate of the highest, the difference surviving controls for smoking and obesity. Crucially it was a social gradient — each step down the hierarchy carried higher mortality — so this is not poverty but relative position. Whitehall II reproduced it among women.
- Richard Wilkinson and Kate Pickett (The Spirit Level, 2009) extended it: among rich countries it is the degree of income inequality, not average income, that predicts life expectancy.
The Indian evidence
India’s gradient is steeper, running along region and social group as much as income.
- SRS 2023 records infant mortality at 25 per 1,000 — rural 28, urban 18 — but 37 in Madhya Pradesh, Uttar Pradesh and Chhattisgarh against 5 in Kerala.
- The maternal mortality ratio is 88 per 100,000 live births (2021-23), down from 130 in 2014-16; the older state spread ran from Kerala’s 19 to Assam’s 195.
- NFHS-6 (2023-24) puts stunting at 29.3%, from 35.5% — still the nutritional signature of class passed to the next generation.
- The financial mechanism has weakened but not gone: out-of-pocket spending fell from 64.2% of total health expenditure (2013-14) to 43.4% (2022-23), and Ayushman Bharat PM-JAY has issued 44.73 crore cards.
The Indian specificity: caste compounds class
Class alone underestimates the Indian gradient: caste operates as an independent axis. Analysis of NFHS-5 data in the Indian Journal of Medical Research (2024) found under-five mortality among Scheduled Tribes at 50 per 1,000 against an all-India 41.9 — and within Scheduled Tribes, children of rich households still carried adjusted odds of under-five death of 0.742 against poor ones. Caste and class stack rather than substitute. Sukhadeo Thorat (Blocked by Caste, 2010, with Katherine S. Newman) locates the cause in market and non-market exclusion — from land, credit, employment and services — rather than in low income alone.
Conclusion
Amartya Sen and Jean Drèze (Hunger and Public Action, 1989) supply the verdict. Kerala’s mortality is low not because it grew rich but because public action in health, schooling and female literacy preceded prosperity. Growth alone buys mortality decline slowly and unequally; public provisioning buys it faster and more evenly. The class–mortality gradient is therefore not an inevitability of stratification but a measure of how much of the social wage a society has chosen to universalise.